11
Overview of Alcohol Abuse Epidemiology for American Indian Populations

Philip A. May

The body of literature on drinking among American Indians1 has been growing steadily over the past two decades. Since the publication of a comprehensive bibliography on the topic by Mail and McDonald in 1980, several hundred papers have been published in professional journals. Despite the publication of new epidemiological data, much of the life-cycle pattern of alcohol abuse among various Indian groups must be pieced together from a number of very different individual studies. The following discussion attempts to do just this by treating those individual studies as snapshots of a larger process. Thus, the objective is to describe a general pattern of drinking across the life cycle and its effects on the health of American Indians. Because different definitions and criteria were used in these studies, the data are rarely strictly comparable across sites or over time. Nevertheless the number of studies is now sufficiently

   

This paper was prepared with partial funding for clerical assistance provided by Grant No. T34-MH19101. Special thanks to Jan Gossage, Virginia Rood, Phyllis Trujillo and Thomas Welty for their assistance in its preparation. Also special thanks to Aaron Handler of the Office of Program Planning, Evaluation and Legislation of the Indian Health Service, Rockville, Maryland.

1  

''American Indian" is used in this paper as a general term for the approximately 2 million native peoples of North America in the United States and Canada, including Alaska Natives, Eskimo, and Indians. When possible, the exact tribal group being described is named.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 235
--> 11 Overview of Alcohol Abuse Epidemiology for American Indian Populations Philip A. May The body of literature on drinking among American Indians1 has been growing steadily over the past two decades. Since the publication of a comprehensive bibliography on the topic by Mail and McDonald in 1980, several hundred papers have been published in professional journals. Despite the publication of new epidemiological data, much of the life-cycle pattern of alcohol abuse among various Indian groups must be pieced together from a number of very different individual studies. The following discussion attempts to do just this by treating those individual studies as snapshots of a larger process. Thus, the objective is to describe a general pattern of drinking across the life cycle and its effects on the health of American Indians. Because different definitions and criteria were used in these studies, the data are rarely strictly comparable across sites or over time. Nevertheless the number of studies is now sufficiently     This paper was prepared with partial funding for clerical assistance provided by Grant No. T34-MH19101. Special thanks to Jan Gossage, Virginia Rood, Phyllis Trujillo and Thomas Welty for their assistance in its preparation. Also special thanks to Aaron Handler of the Office of Program Planning, Evaluation and Legislation of the Indian Health Service, Rockville, Maryland. 1   ''American Indian" is used in this paper as a general term for the approximately 2 million native peoples of North America in the United States and Canada, including Alaska Natives, Eskimo, and Indians. When possible, the exact tribal group being described is named.

OCR for page 235
--> large and their methodologies sufficiently similar that some broad trends can be established. The next section briefly reviews some stereotypes associated with drinking among American Indians. This is followed by a discussion of the epidemiology of substance abuse among Indian youth. We then turn to a review of findings on alcohol abuse among adult American Indians, examining first survey data and then the results of two longitudinal studies. The discussion next focuses on current data on alcohol-involved mortality among American Indian populations. The problem of fetal alcohol syndrome is then briefly examined. The chapter ends with a discussion of potential preventive measures, followed by a summary of findings and areas for future research. Stereotypes Of Indian Drinking There are a number of commonly held stereotypes with regard to alcohol use and abuse among American Indians (May 1994a, 1994b). One of the most pervasive of these is that Indians metabolize alcohol more slowly or differently than other ethnic groups. Approximately a dozen studies have now been published on the biophysiology of alcohol processing among American Indians (see, for example, Bennion and Li, 1976; Reed et al., 1976; Schaefer, 1981; Rex et al., 1985; Segal and Duffy, 1992). In general, the findings have shown that American Indians metabolize alcohol in a manner and at a speed similar to those of other ethnic groups in the United States (Bennion and Li, 1976); that there is a great deal of variation in alcohol processing within American Indian and Alaska Native ethnic groups (Reed et al., 1977; Segal and Duffy, 1992); that prior drinking experience and body weight are very influential in the metabolism process (Bennion and Li, 1976); and that overall liver structures among American Indians are not unique, and their liver phenotypes are similar to those of other, particularly European, ethnic groups (Rex et al., 1985). Thus, the findings of these studies are in keeping with those of studies conducted among ethnic groups throughout the world. It is also said that American Indian drinking patterns and problems are uniquely Indian. However, review of the epidemiologic statistics of American Indians shows that high rates of alcohol problems among American Indians are influenced by many of the same factors or traits that influence drinking among other groups. Of particular importance are variables such as age, geography, social norms, and political and legal policies. Special combinations of these influences have created particular patterns of drinking and alcohol-involved injury, death, and arrest that are high to very high, and therefore perceived to be uniquely Indian when in fact they may not be (May, 1994a). Furthermore, the literature describes

OCR for page 235
--> variation in alcohol consumption from one tribal culture to the next. There are some high-risk/rate groups, and there are also many low-risk/rate groups (see Levy and Kunitz, 1974; May et al., 1983; May, 1991; Kunitz and Levy, 1994; Young, 1994:Chapter 6). Studies show that the style of drinking also varies among American Indians, spanning the four commonly mentioned styles of abstinence, moderated social drinking, heavy recreational drinking, and anxiety or chronic alcohol-dependent drinking (see Ferguson, 1968; Levy and Kunitz, 1974; May, 1992). Many studies support the commonly held belief that alcoholism and alcohol abuse are epidemic among some tribal populations (see, for example, Brod, 1975; Lamarine, 1988; Littman, 1970; Swanson et al., 1971; Stratton, 1973; Stewart, 1964). Yet the arrest and morbidity data used for these studies are frequently not descriptive of individual behavior; rather, they are aggregate data that reflect duplicate counts of arrests and problems generated by a select number of individuals. Thus the impression is given that many more individuals are involved in the deviant behavior than is actually the case (see, for example, Ferguson, 1968; May, 1988). Epidemiology Of Indian Youth Substance Abuse From Surveys There is a substantial body of literature on substance abuse among American Indian youth. Most of this literature is based on a large number (several hundred) of high school substance abuse surveys administered across the nation (see Oetting et al., 1988, 1989; Beauvais, 1992; Swaim et al., 1993). In general, the survey literature indicates that, on average, rates of lifetime use and abuse of many drugs, including alcohol (and getting drunk), are higher among American Indian than non-Indian youth. Specifically, drug surveys among Indian youths reveal similar or slightly higher rates of current use of alcohol (particularly higher for getting drunk), cocaine, inhalants, stimulants, barbiturates (downers), and other drugs. At the same time, Indian youth are less prone to use some other drugs (heroin and PCP). Nonreservation Indians have the highest use rates of most drugs in high school surveys.2 Other studies corroborate the general points made above (Winfree and Griffiths, 1985; Winfree et al., 1989). Youthful drinking of alcohol, as well as some experimentation with other drugs among Indian youth peer 2   It should be noted that while the above studies generally present averaged data for a variety of high schools in a variety of locales, there is substantial variation among high schools in different communities (Liban and Smart, 1982; May et al., unpublished data).

OCR for page 235
--> groups who drink, is described as predominantly recreational (Beauvais, 1992). Heavy bingeing may occur on weekends (at night) and during the summer when parents are not present, at parties, and on other special occasions. The pattern is similar to that among other youths in the United States, yet the settings (e.g., rural reservations and urban Indian neighborhoods) and norms of comportment are slightly to greatly different (Topper, 1980). Various authors have provided consistent explanations of the etiology of substance abuse among American Indian youth. Most of these explanations are similar to those found in the mainstream literature. For example, Oetting and Beauvais (1989) have demonstrated that self-esteem and many isolated social/psychological variables do not differentiate between heavily substance abusing Indian youths and others. Rather, the authors point to association and identification with abusing peer clusters as the most influential factor in causing persistent and serious substance abuse and polysubstance abuse among Indian youths (see also Swaim et al., 1993). Other researchers make similar observations, attributing drinking and other substance abuse problems among Indian youth to differential association with subcultures of abuse and the social learning that occurs within them (Winfree et al., 1989; Sellers and Winfree, 1990). But rather than being fueled by a white youthful "hang loose" ethic, Indian peer groups may be more likely to interpret heavy drinking as an "Indian thing to do" (Winfree and Griffiths, 1985; Winfree et al., 1989; Lurie, 1971; Mohatt, 1972; Graves, 1971). In addition to the above themes, the literature has identified other variables within some communities as influential in substance abuse among Indian youth (Winfree and Griffiths, 1985). Of particular importance is the influence of norms in the home as a predisposing factor to association with abusing peer groups (see Oetting and Beauvais, 1989; Beauvais, 1992). Adult Alcohol Abuse Surveys There have been eight major studies concerned with the prevalence and epidemiological features of drinking among adult Indian populations, as well as three survey samples of older adults recently completed as part of a cardiovascular disease study. Table 11-1 lists the prevalence rates for alcohol use among the populations sampled for these studies, along with the rate among the general U.S. population for comparison. It is important to note that different definitions and criteria were used in these studies, and that the data are not always comparable across sites or over time. Overall, however, these studies support a number of generalizations:

OCR for page 235
--> TABLE 11-1 Prevalence of Alcohol Use Among Adults: Various Indian Tribes, Older Indian Adults, and U.S. General Population   % Current Users in Population Sample Total Male Female Source U.S. General Population         1983 (ages 18+) 61.0 72.0 50.0 NIAAA, 1993 1985 (ages 18+) 57.0 68.0 47.0 NIAAA, 1993 Standing Rock Sioux         1960 (ages 15+) 69.0 82.0 55.0 Whittacker, 1962 1980 (ages 12+) 58.0 72.0 35.0 Whittacker, 1982 Cheyenne River Sioux         1988 (ages 18+) 45.9 — — Welty, 1989 Navajo         1969 (ages 18+) 30.0 52.0 13.0 Levy and Kunitz, 1974 1984 (ages 16+) 52.0 64.0 40.0 May and Smith, 1988 Ute         1966 (no age specified) 80.0 — — Jessor et al., 1968 Ojibwa         1978 (ages 18+) 84.0 — — Longclaws et al., 1980 Lumbee         1978 urban (ages 21-64) 72.6 — — Beltrane and McQueen, 1979 1978 rural (ages 21-64) 45.7 — — Beltrane and McQueen, 1979 Cheyenne River, Devil's Lake, and Oglala Sioux         1989-1992 (ages 45-74) 47.4 60.0 37.7 Welty et al., 1995 Central Arizona Pima, Maricopa, Papago         1989-1992 (ages 45-74) 40.3 57.4 30.5 Welty et al., 1995 Southwestern Oklahoma, Apache, Caddo, Delaware, Comanche, Kiowa, and Wichita         1989-1992 (ages 45-74) 36.8 49.0 27.9 Welty et al., 1995 There is tremendous variation in the prevalence of drinking from one reservation to the next and also from one time period to the next. Every study shows that fewer Indian women than men drink. The more recent Indian studies show less drinking among Indians than among the general U.S. population; however, there is variation in the overall study results, with the older studies among the Ute and Canadian  

OCR for page 235
--> Ojibway indicating higher prevalence. Thus there may be some Indian populations in which a higher proportion drinks than in the U.S. general population, some in which the prevalence is similar to general U.S. levels, and some in which the prevalence is lower. Urban Indian populations generally have a higher prevalence of drinking than do many reservation populations, whereas reservation populations generally have a higher prevalence of abstention. For example, the Lumbee adult study, a study among the Navajo, and Indian youth studies clearly illustrate this pattern (Beltrame and McQueen, 1979; Levy and Kunitz, 1974; Beauvais, 1992).   The variations over time and by tribe are illustrated in studies of the Standing Rock Sioux (Whittacker, 1962, 1982) and the Navajo (Levy and Kunitz, 1974; May and Smith, 1988). Among the Standing Rock Sioux, study results in 1960 indicated a prevalence of drinking similar to that of the U.S. population (Whittaker, 1962), whereas by 1980, the prevalence of drinking had dropped below national averages; this decrease in drinking rates was particularly true for Sioux females (Whittaker, 1982). From a 1969 study of the Navajo, Levy and Kunitz (1974) report a vastly lower proportion of drinking among the tribal population than among the U.S. population; by 1984 however, the proportion of Navajo drinking had risen substantially (May and Smith, 1988). Yet even with this increase, the proportion of Navajo drinking in the 1980s was still less than that of the general U.S. population. Patterns of Heavy Use Generally, the studies listed in Table 11-1 reveal a number of indicators of problem drinking among these tribal groups, with the various heavy drinking measures being two to three times the magnitude found among the general U.S. population. Particularly evident in a number of the studies is a tendency toward heavy binge drinking (more than five to seven drinks per episode) and highly adverse results from drinking, such as delirium tremens and blackouts. For example, among the Cheyenne River Sioux (Welty et al., 1988), 37 percent of the respondents had consumed five or more drinks on at least one occasion in the previous month, whereas 29 percent of other South Dakotans had done so (Welty et al., 1988).3 Furthermore, among the Navajo and Standing Rock Sioux, a large 3   Both Indian and non-Indian groups in South Dakota are high on this measure and on driving after drinking as well; on the latter measure, the non-Indians exceed the Indians by 8.3 to 11.6 percent.

OCR for page 235
--> number of the male drinkers were classified as heavy or abusive drinkers by standard indicators of quantity, frequency, and variability of drinking. Similar measures were substantially less prevalent among the general U.S. population. Therefore, among those Indians who do drink, most surveys of adult drinking find that there is a very high percentage of heavy drinkers, particularly heavy binge drinkers. The study among urban and rural Lumbee Indians (Beltrane and McQueen, 1979) makes several important points. First, urban Lumbees drink more than rural Lumbees and have higher rates of problem drinking. Second, traditional social norms among the rural North Carolina Lumbees result in more abstinence and a highly age-specific pattern similar to that found in other reservation Indian studies. Third, occupational considerations (prestige and satisfaction) are much more highly related to Indian drinking in the urban area (Baltimore) than among the rural sample. Finally, heavy drinking is most common among the lower social strata of the urban area residents. Such findings may be consistent with those for other Indians in urban areas, but this topic awaits further study. Less-Problematic Patterns The studies listed in Table 11-1 also show some less-problematic patterns of alcohol use among Indians: There is a substantial proportion of most tribal populations that practices total abstinence (nothing to drink in the previous year). There are many American Indian males in virtually every tribal community who have been problem or heavy drinkers in the past, but have quit in early or later middle age (e.g., early 30s to middle 40s), generally without the assistance of an alcohol treatment program. The abstention rate among Indian females is particularly high as compared with other U.S. females. There are some tribes in which drinking is confined to a relatively small proportion of the population.   These observations are underscored among the older adult samples (ages 45-74) examined by Welty et al. (1995). Generally, only 36-47 percent of this age group surveyed in 13 tribal sites was still drinking. The male drinkers still outnumbered the female by approximately two to one (Welty et al., 1995), but only half of the males were still drinking by their mid-50s. Thus Indian male-female differences in drinking prevalence appear to be substantial throughout the life span. Indicators of heavy use were also substantially lower among these older adult samples. There was less binge drinking reported at these later ages, although the indicators

OCR for page 235
--> of binge drinking still existed, particularly among samples from the Dakotas and Arizona. Indeed, indicators from Welty et al.'s (1995) study suggest that binge drinking, not chronic use, is the most common pattern at these ages. For example, less than 20 percent of the male current drinkers and 10 percent of the female current drinkers had had more than 14 drinks in the previous week. Also, current drinkers in this age group averaged fewer than 11 drinks per week (males 8 to 10 and females 4 to 6). In general, these studies among older adult Indians reinforce two important points. First, the recreational drinking pattern of sporadic bingeing persists among many Indian drinkers throughout the years during which they drink. Second, many Indian males reach a turning point in their 30s and 40s that influences them to quit drinking completely (see Levy and Kunitz, 1974; Kunitz and Levy, 1994; Leung et al., 1993). More study of this phenomenon is needed for two reasons. First, it is important to understand why this phenomenon of "maturing out" occurs frequently among many Indian tribes (particularly among males). Second, such knowledge might enable professionals to apply some new insights and techniques to Indian alcohol rehabilitation and prevention programs, thus fostering sobriety and reducing harm from drinking at earlier ages (May, 1995). The most complete examination to date of maturing out was conducted by Kunitz and Levy (1994). Among a sample of Navajo men who had stopped all drinking in their middle and later years, the following reasons were given: 42 percent said their health had been in jeopardy, 20 percent had joined the Native American church (which provides spiritual support and also prohibits drinking among its members), 18 percent said their responsibilities had dictated that they quit, 9 percent had found drinking unrewarding, and 4 percent had joined an established Protestant church. In general, Kunitz and Levy conclude that those who mature out leave life-styles/social groups/communities of friends who are supportive of drinking and find social and community support that reinforces abstinence behavior and values not related to drinking. Longitudinal Follow-Up Studies Of Adult Indian Drinkers Two longitudinal studies of adult Indian drinkers provide significant findings about drinking careers among the adult American Indian population. A study by Leung et al. (1993) resurveyed respondents in a northwest coastal village 19 years after a baseline mental health epidemiology survey (Shore, 1974). A very high rate of cessation of drinking (60-63 percent) was found among adult drinkers over this time period. Men and

OCR for page 235
--> women were found to drink very differently throughout the various ages. The present prevalence rates of alcoholism changed from 52 percent for men and 26 percent for women in 1970 to 36 and 7 percent, respectively, in the 1990s. The aging of the sample population had altered the prevalence of problem drinking. Women had a higher remission rate (82 versus 52 percent for males), but were also more likely to have been or to be alcohol abusers (rather than alcoholics) when drinking. Men were very likely (about 75 percent) to have been alcohol dependent at one time in their adult years and to have stopped after an average of 15 years of heavy drinking. The vast majority (83 percent) ceased drinking without the aid of treatment for alcohol misuse. Of the initial subjects who were found to have an alcohol problem, 22 percent had the same diagnosis in the second survey, 41 percent had stopped drinking, 17 percent had died of alcohol-related causes, and 20 percent had died of other causes (Leung et al., 1993). Men and women participants in an extensive study of drinking conducted in 1969 (Levy and Kunitz, 1974) were located and followed up after 21 years (Kunitz and Levy, 1994). Most of the men were found to have stopped drinking at the time of follow-up or prior to their death. Male social drinkers were most likely (80 percent) to have stopped, while male solitary drinkers were less likely to have done so. Male solitary drinkers were also more likely to have died from alcohol-related causes, particularly those men who came from a wage work community (27 percent mortality) and from a group that had been hospitalized for problems in 1969 (38 percent mortality). Rural, culturally more traditional drinkers were found to have a lower prevalence of drinking and to have suffered fewer problems at follow-up. Both the differential drinking rates of Navajo males and females and the fact that many Navajos are able to stop drinking are cited by Kunitz and Levy as evidence that the majority of Navajo drinkers and the nature of their alcohol-related outcomes are shaped predominantly by culture (Kunitz and Levy, 1994). Current Data On Alcohol-Involved Mortality Mortality Rates Table 11-2 presents current data (1987-1989) on alcohol-involved4 mortality for U.S. Indians and Alaska Natives.5 These 3-year averages for 4   Three terms are used in this section to define mortality types and their link to alcohol. Alcohol-specific deaths are those that have a clear, highly unitary causal connection with heavy alcohol ingestion (e.g., cirrhosis with alcohol specified and alcohol dependence syndrome). Generally, these deaths are due to chronic diseases caused by alcohol consumption

OCR for page 235
--> Indians are compared with U.S. general population data6 for 1988 by age, sex, rates per 100,000, and number of deaths. At the top of Table 11-2, the male age-specific death rates are presented for key categories. For the highly alcohol-related causes of death, such as motor vehicle crashes, other accidents, suicide, homicide, and alcoholism, Indian males have higher rates of death in every age and cause category, with the exception of suicide deaths for older ages. By age 55, Indian males have lower rates of suicide mortality, a pattern that continues into the later ages. But for all other causes of death, the mortality rates and ratios are substantially higher. For motor vehicle accidents, other accidents, and homicides, the rates are generally 1.4 to 3.9 times higher for Indian males than the U.S. averages. The ratios are even higher for the alcohol-specific category, alcoholism deaths. Alcoholism death rates among Indian males aged 15-24 are 13 times higher than U.S. averages, for ages 25-34 they are 8.8 times higher, and for ages 35-74 they are 3.3 to 5.4 times higher. Therefore, the data indicate that alcohol-related mortality is a substantially greater problem for Indian males than for males in the general U.S. population. For female rates of death, Table 11-2 indicates somewhat similar results. Indian females die much less frequently than Indian males but more frequently than other U.S. females from all alcohol-related causes, with the sole exception of suicide rates above age 44. Similarly, the ratio of alcohol-related mortality for Indian females and U.S. females is even higher than the male ratio. Alcohol-related mortality is 1.2 to 3.5 times higher than U.S. averages. Individual alcohol-specific death rates (which     over many years, but not always (e.g., alcoholic psychosis or alcohol overdose). Alcohol-related deaths denote those causes, such as suicide, homicide, and vehicle crashes, in which alcohol is a highly necessary factor in the majority of deaths, but not a sufficient factor. In many cases, alcohol-related deaths are from injuries resulting from alcohol impairment, but not always (e.g., exposure). Alcohol-involved death is an all-inclusive term that includes both of the above categories. 5   Data are for Indians identified as living in the 35 reservation states served by the Indian Health Service. 6   Kunitz and Levy (e.g., Kunitz and Levy, 1994; Levy and Kunitz, 1987) caution against comparison of Indian mortality rates with those of the general U.S. population. They rightfully point out that some rural Indians, particularly in the southwestern United States, generally manifest patterns of mortality from suicide, homicide, and some other social pathologies that are similar to those of their non-Indian neighbors in the surrounding areas, and that patterns for both Indians and non-Indians in the West are different from overall U.S. patterns. However, as shown in some other studies, this observation does not always hold true for motor vehicle crashes (May, 1989b); suicides (Van Winkle and May, 1993); or other causes, such as alcoholism (New Mexico Department of Health, 1994). Furthermore, in this discussion, U.S. Indian averages (not averages for specific tribes) are presented, so U.S. averages provide more appropriate comparisons than specific tribal or regional studies.

OCR for page 235
--> are related primarily to cirrhosis and alcohol dependence syndrome) for Indian females ages 15-24 are 31 times higher than U.S. average, 7 13.3 times higher for ages 25-34, and 4.6 to 8.4 times higher for ages 35 and above. It therefore seems evident that alcoholism and alcohol-dependent mortality not only affect a disproportionate number of Indian women, but particularly affect the younger ages. Male And Female Alcohol-Involved Deaths As A Percentage Of All Deaths The estimated numbers of deaths from alcohol-involved causes are given in the far right columns of Table 11-2. For U.S. Indian males in 1987-1989, there were 3,754 deaths from alcohol-involved causes. However, not all of these deaths were truly alcohol-involved. We estimate the magnitude of alcohol-involved causes by multiplying these deaths by an approximate proportion of alcohol involvement established from existing studies of these phenomena among American Indians (see May, 1989a, 1992).8 On the basis of these calculations, it is estimated that 2,382 males and 783 females died from alcohol-involved causes during this 3-year time period. Deaths from alcohol-involved causes among males are estimated to be responsible for 13 percent of all Indian deaths and 22 percent of all male deaths during the period. Female alcohol-involved deaths are estimated to be responsible for 4.3 percent of all Indian deaths and 10.4 percent of all female Indian deaths. Overall then, 17.3 percent of all Indian deaths in 1987-1989 can conservatively9 be estimated as having been alcohol-involved. Age-Adjusted Rates Table 11-3 shows the age-adjusted mortality for American Indians for more recent years, 1989-1991. The estimated alcohol involvement has been calculated for this table as well, and rates, numbers, and percentages of death are presented. The conclusion from this table with regard to all 12 Indian Health Service areas is that the age-adjusted alcohol-related death rate among American Indians is 2.4 times that of the general U.S. 7   Small numbers in this age group invite caution in interpretation, however. 8   These estimated proportions were developed from the published literature on American Indians and studies conducted by the author and his colleagues over the past two decades (see May, 1988, 1992). 9   These estimates are likely to be conservative since alcohol-related heart disease, cerebrovascular disease, cancer, diabetes complications, and infectious diseases have not been considered.

OCR for page 235
--> the data by separating alcohol-related and alcohol-specific causes is highlighted in the discussion of preventive measures in the next section. Explanations of Tribal Variations in Rates Explanations for the variations in alcohol-involved behavior among tribes have been proposed and tested for several decades in the Indian literature (see Levy and Kunitz, 1974, and May, 1977b and 1982, for reviews). The themes used are variations of Durkheim's (1957) Social Integration Theory, put forth to explain suicide. Social integration refers to the processes that make a society whole from a collection of individuals. It also refers to how the individual is attached symbolically and structurally to the larger social aggregates, such as the family and social, political, and religious groups (Jessor et al., 1968). Overall, American Indian tribes have levels of traditional social integration that have been classified by anthropologists as ranging from high to low (see Field, 1991, and Levy and Kunitz, 1974:Chapter 3, for specifics related to tribal alcohol patterns; see Davis, 1994, and Champagne, 1994, for general discussion). In low-integration societies, the individual is a member of fewer permanent groups, and the main reference groups are less likely to impose on the individual clear and strong mandates for conformity. Therefore, the individual has more freedom to define his or her own behavior. In high-integration societies, the opposite is true: the individual is expected to conform to clearer and more formal mandates of the social groups to which he or she belongs. Tribes that have high traditional integration have lower rates of alcohol misuse and alcohol-involved problems than those with low integration (Field, 1991; Levy and Kunitz, 1974). However, when modernization, acculturation stress, and other social disorganizing forces are brought to bear on Indian social systems, rates of alcohol-related pathology rise (see Dozier, 1966). This is particularly true when family structure is affected (Jenson et al., 1977). Therefore, when a low-integration tribe is being affected by high rates of pressure from mainstream society, the highest average rates of alcohol-misuse problems result, whereas a high-integration tribal community under little pressure to modernize will generally have the lowest rates of alcohol abuse (for more detail see May, 1982). These concepts, it should be added, are equally important in understanding sociocultural influences in non-Indian societies (Jessor et al., 1968; Pittman and White, 1991). The rates of alcohol-related problems and alcohol-involved mortality from area to area and tribe to tribe generally conform to these patterns.

OCR for page 235
--> Fetal Alcohol Syndrome Fetal alcohol syndrome (FAS) and other alcohol-related birth defects vary greatly from one Indian community to the next (May et al., 1983). While no major study has been done on an urban Indian group, very complete surveys have been carried out in nine reservation areas in the United States and Canada (May, 1991). It was found that 15-year retrospective, population-based rates of FAS in the southwestern United States were lowest among the Navajo (1.6/1000 births), intermediate among the Publo (2.2), and highest among two southwestern plains culture tribes (10.3). The comparable U.S. estimate is 2.2. Overall, the rates vary quite predictably, given the level of social integration and drinking patterns among these tribes (May et al., 1983). A higher proportion of females in low-integration, plains culture groups drink (indulging particularly in heavy bingeing), and therefore the FAS rates among these groups are higher. In two studies of heavy-drinking Indian communities in Canada and Alaska, very high FAS rates were found where there were low integration and normative patterns of female drinking that allowed a high proportion of women to drink and to participate in frequent and very heavy binge drinking (Asante and Nelms-Matzke, 1985; Robinson et al., 1987). A consistent finding is that FAS and most alcohol-related birth defects occur to a small number of women, 6.1/1000 women of childbearing age among seven Southwestern Indian communities (May et al., 1983). This finding reflects the drinking patterns in many tribes: a majority, or at least a very high percentage, of the women are abstainers, but among those who drink, there is generally a rather limited subset of women who are very heavy drinkers. In fact, many of these women are so severe in their alcohol involvement that they frequently have a number of alcohol-damaged children (1.3 to 1.6 per mother) before an almost inevitable, untimely alcohol-specific or alcohol-related death (see May et al., 1983; May, 1991). Therefore, these women pose a substantial challenge to intervention and prevention programs (Masis and May, 1991). Prevention Of Alcohol Problems Indian alcohol problems are influenced mainly by norms related to drinking and post-drinking behavior among the heavy-drinking sub-segment of the population (Dozier, 1966; Stewart, 1964; Levy and Kunitz, 1974; May, 1976; Kunitz and Levy, 1994; MacAndrew and Edgerton, 1969). Preventive efforts to alter attitudes, beliefs, and social structures offer the promise of reducing alcohol misuse and resultant problems (see Jessor et al., 1968; May, 1992, 1995).

OCR for page 235
--> An example of sociocultural change for the prevention of alcohol abuse problems, well portrayed in videos and frequently presented at workshops, is offered by Alkali Lake, a British Columbia Indian community. Over the course of a few years, this community achieved a striking reduction in problems with alcohol dependence and misuse—reportedly from 95 percent alcohol abusive or alcoholic to 95 percent alcohol free. This change was accomplished through community organization around principles of abstinence and group support taken from the traditions of Alcoholics Anonymous (Guillory et al., 1988). These values and traditions were advocated by selected leaders and eventually gained wide acceptance as specific means to promote and maintain abstinence from alcohol consumption. Tactics used included moral persuasion; social policies to control alcohol possession, sale, and consumption; and economic sanctions. In addition, traditional Indian spiritual and cultural activities were reintroduced to reinforce abstinence and to improve and maintain social functioning in a historical, cultural, and spiritual sense (see Guillory et al., 1988). The patterns of alcohol-related problems highlighted here raise a number of public health issues. Before one begins prevention or intervention efforts in any Indian community, it is vital to have data that are locally specific. The motivation of a community to change must also be considered before any prevention initiative is undertaken (May et al., 1993). The extant data warrant many public health approaches. These approaches are grouped below under the standard prevention terminology of primary, secondary, and tertiary levels (Bloom, 1981; May and Moran, 1995). Primary Prevention Primary prevention consists of measures taken to stop a problem in its developmental stages, or in other words to keep the problem from arising (Last, 1988). In general, a comprehensive, community-wide program of alcohol-misuse prevention should embrace two general approaches: motivating populations to change and changing the environment to make it more protective (May et al., 1993). The goal of these programs is to keep problematic and heavy alcohol use from causing premature morbidity and mortality so that individuals remain healthy and live long enough to mature out of youthful and young adult drinking patterns. In many cases, public education has been undertaken as the major form of primary prevention. In one survey of the Navajo population (May and Smith, 1988), 63 percent of all Navajos agreed with the statement

OCR for page 235
--> that ''Indians have a biological weakness to alcohol that non-Indians do not have," even though this is an erroneous statement in light of scientific evidence. Such beliefs must be transcended before it becomes possible to motivate positive behaviors. Alcohol policy has not received much attention as it affects alcohol-involved problems among Indians. For example, tribes have an almost absolute power to regulate the possession, sale, consumption, and taxing of beverages on reservation (May, 1977a). Yet few evaluations of such policies have been undertaken (May, 1976; Landen, 1993). New studies are warranted, for policy has been found to be very influential in many communities (Beauchamp, 1980; May, 1992), and some tribes are now involved in major policy-directed efforts (Van Norman, 1992). In one "natural experiment," the fetal alcohol syndrome rate in a small Indian community dropped from 14/1000 to zero for a 5-year period as the latent consequence of a change in economic policy that suspended monthly payments of gas and oil royalties to individual families (May, 1991). In other cases, alcohol-related arrests have been reduced by 30 to 60 percent because of policies related to alcohol availability (May, 1975, 1976). Also, alcohol-involved mortality has been found to be up to 20 percent lower over a 15-year period on reservations having policies of alcohol availability believed to encourage norms of more controlled drinking (May, 1976). Secondary Prevention Secondary prevention measures are those taken to recognize and arrest a problem in its earliest stages (Last, 1988). In few communities in the United States is early detection of problem drinkers undertaken or practiced by healthcare and social service providers for either males or females. Indian communities are not a major exception. Social detoxification centers that screen and assess drinking problems among individuals could be set up as extensions of, or diversions from, the criminal justice system. Early detection of problem drinkers in Indian communities could be instituted in routine health settings as well. Also of great promise in the secondary arena is the institution of brief motivational therapeutic interventions for Indian populations. As practiced among other populations, such interventions might provide cost-efficient alcohol therapy for drinkers who have not yet developed severe dependency or other extreme levels of alcohol misuse (Miller and Rollnick, 1991). Brief motivational therapies could be used in lieu of expensive inpatient therapy, which is commonly used yet relatively unsuccessful among Indians today. Furthermore, brief therapies could be used to speed up or better prepare Indian males who are in the early stages of maturing out, which, as noted earlier, is now becoming recognized

OCR for page 235
--> as a common pattern among Indians (see Arbogast, 1995, for case studies of this process). Tertiary Prevention At the tertiary level of prevention, the problem condition—alcoholism or severe alcohol misuse—is already present in an individual (see Last, 1988). Indian alcohol abuse treatment programs are available to deal with the problems at this level. However, those programs have been criticized in the literature as being understaffed and insufficient to meet the needs (see Shore and Von Fumetti, 1972; Wilson and Shore, 1975; Shore and Kofoed, 1984; May, 1986). Indian treatment programs might be substantially improved by upgrading services and redesigning them to take advantage of the maturing-out process. Furthermore, Indian programs seldom have special provisions for Indian females. This must be changed, as too many Indian females who do drink cause an unacceptably high level of alcohol-specific death. The literature (May, 1991) indicates a very strong need for tertiary care for women who produce children with fetal alcohol syndrome and other alcohol-related birth defects (Masis and May, 1991). Indian mothers (and mothers of other ethnic groups) who produce one such child frequently progress in their problem drinking to produce a second, third, or subsequent number of alcohol-affected children (May et al., 1983). In such cases, tertiary care delivered in sheltered environments (e.g., half-way houses) could prove to be very important, yet few such programs exist. Social detoxification centers, mentioned above under secondary prevention, can also be an important tool for tertiary prevention. Individuals in advanced states of alcohol misuse could be identified in detox centers and aggressively referred to alcohol treatment and other therapeutic health and behavioral interventions. Summary Of Findings And Areas For Future Research There is a great deal of heavy and problematic drinking and therefore alcohol-involved mortality among American Indians, but there are a number of positive findings as well. While the rates of heavy drinking for youth and adults and rates of death from alcohol-involved causes are very high overall, a lower proportion of the adult population in many of these groups is drinking. Therefore, the problem of alcohol misuse is highly concentrated within most Indian communities. Furthermore, there is substantial variation from one community to the next in the overall prevalence of drinking. Yet the existence of subgroups of heavy drinkers

OCR for page 235
--> within many tribal communities results in extremely high rates of death, arrest, and other alcohol-related social problems. A number of research topics related to the epidemiology of alcohol problems among American Indians need to be pursued. First, the data presented here describe a pattern that is rather common across the life cycle in many Indian communities. That is, from a high prevalence of drinking (almost universal in the late teens) and experimentation with drugs in the teens and early 20s among most Indians, various drinking styles evolve in the late 20s through the mid-40s. These drinking styles range from abstinence to some isolated, very heavily alcohol-dependent patterns. The bulk of the alcohol-related problems surrounding heavy recreational and binge drinking occur from the late teens through the mid-30s, and alcohol dependency problems increase dramatically from ages 25 through the late years among a select minority of the Indian population. Confirmation of these life-cycle trends is needed. Furthermore, there is very little literature currently available on alcohol-specific causes of death among Indians. Epidemiologic or biomedical analyses of Indian deaths from liver cirrhosis or other alcohol-specific causes are badly needed. As is the case among the population generally, there have been virtually no prevention trials examining what public health measures or prevention programs are effective in Indian communities. Therefore, research is needed to address the question, "Does prevention work?" Studies of treatment for alcohol misuse and dependence are also lacking among Indian populations. Very few studies of treatment effectiveness have been undertaken among Indians, and they are severely needed. Furthermore, many Indian alcohol programs offer a narrow, and often unsophisticated, range of treatment modalities. A broader range of both new and old treatment modalities of proven effectiveness should be pursued and their results carefully studied. Evaluation of effectiveness would be particularly important for programs using traditional, culture-based therapies as well as mainstream therapies. As most Indian populations include a variety of individuals with a broad range of both traditional and modern traits, biculturalism and acculturation are important concepts for treatment and research in such programs and for evaluation of the effectiveness of various programs for individual clients. References Arbogast, D. 1995 Wounded Warriors: A Time for Healing. Omaha, NE: Little Turtle Publishers. Asante, K.O., and J. Nelms-Matzke 1985 Report on the Survey of Children with Chronic Handicaps and FAS in the Yukon and Northwest British Columbia. Terrace, B.C.: Mills Municipal Hospital.

OCR for page 235
--> Beauchamp, D.E. 1980 Beyond Alcoholism: Alcohol and Public Health Policy. Philadelphia: Temple University Press. Beauvais, F. 1992 Indian adolescent drug and alcohol use: Recent patterns and consequences. American Indian and Alaska Native Mental Health Research 5(1):1-67. Beltrame, T., and D.V. McQueen 1979 Urban and rural Indian drinking patterns: The special case of the Lumbee. The International Journal of the Addictions 14(4):533-548. Bennion, L., and T-K Li 1976 Alcohol metabolism in American Indians and whites. New England Journal of Medicine 284:9-13. Bloom, M. 1981 Primary Prevention: The Possible Science. Englewood Cliffs, NJ: Prentice-Hall, Inc. Brod, T.M. 1975 Alcoholism as a mental health problem of Native Americans. Archives of General Psychiatry 32(11):1385-1391. Champagne, D., ed. 1994 The Native North American Almanac. Detroit, MI: Gale Research, Inc. Davis, M.B., ed. 1994 Native American in the Twentieth Century: An Encyclopedia. New York: Garland Publishing, Inc. Dozier, E.P. 1966 Problem drinking among American Indians: The role of sociocultural deprivation. Quarterly Journal of Studies on Alcohol 27:72-84. Durkheim, E. 1957 Suicide. New York: The Free Press. Ferguson, F.N. 1968 Navajo drinking: Some tentative hypotheses. Human Organization 27:159-167. Field, P.B. 1991 A new cross-cultural study of drunkenness. Pp. 48-74 in D.J. Pittman and C.R. Snyder, eds., Society, Culture and Drinking Patterns . New York: Wiley. Graves, T.D. 1971 Drinking and drunkenness among urban Indians. Pp. 275-311 in J. Waddell and O.M. Watson, eds., The American Indian in Urban Society . New York: Little, Brown and Company. Guillory, B., E. Willie, and E. Duran 1988 Analysis of a community organizing case study: Alkali Lake. Journal of Rural Community Psychology 9(1):27-35. Indian Health Service 1993 Trends in Indian Health 1993. Rockville, MD: U.S. Department of Health and Human Services. 1994a Trends in Indian Health 1994. Rockville, MD: U.S. Department of Health and Human Services. 1994b Regional Differences in Indian Health. Rockville, MD: U.S. Department of Health and Human Services. Jenson, G., J. Stauss, and V. Harris 1977 Crime, delinquency, and the American Indian. Human Organization 36(3):252-257. Jessor, R., T.D. Graves, R.C. Hanson, and S.L. Jessor 1968 Society, Personality and Deviant Behavior: A Study of Tri-Ethnic Community. New York: Holt, Rinehart, and Winston.

OCR for page 235
--> Kunitz, S.J., and J.E. Levy 1994 Drinking Careers: A Twenty-five Year Study of Three Navajo Populations . New Haven: Yale University Press. Lamarine, R.J. 1988 Alcohol abuse among Native Americans. Journal of Community Health 13(3):143-155. Landen, M.G. 1993 Alcohol-related Mortality and Tribal Alcohol Legislation. Master's Thesis. University of North Carolina. Last, J.M., ed. 1988 A Dictionary of Epidemiology, 2nd edition. New York: Oxford University Press. Leung, P.K., J.D. Kinzie, J.K. Boehnlein, and J.H. Shore 1993 A prospective study of the natural course of alcoholism in a Native American village. Journal of Studies on Alcoholism 54:733-738. Levy, J.E., and S.J. Kunitz 1974 Indian Drinking. New York: Wiley Interscience. 1987 A suicide prevention program for Hopi youth. Social Science and Medicine 25(8):931-940. Levy, J.E., S.J. Kunitz, and M. Everett 1969 Navajo criminal homicide. Southwestern Journal of Anthropology 25(2):124-152. Libran, C.B., and R.G. Smart 1982 Drinking and drug use among Ontario Indian students. Drug and Alcohol Dependence 9:161-171. Littman, G. 1970 Alcoholism, illness, and social pathology among American Indians in transition. American Journal of Public Health 60(9):1769-1787. Longclaws, L., G. Barnes, L. Grieve, and R. Dumoff 1980 Alcohol and drug use among the Brokenhead Ojibwa. Journal of Studies on Alcohol 41(1):21-36. Lurie, N.O. 1971 The world's oldest ongoing protest demonstration: North American Indian drinking patterns. Pacific History Review 40(3):311-322. MacAndrew, C., and R.B. Edgerton 1969 Drunken Comportment: A Sociological Explanation. Chicago: Aldine. Masis, K.M., and P.A. May 1991 A comprehensive local program for the prevention of FAS. Public Health Reports 106(5):484-489. May, P.A. 1975 Arrests, alcohol, and alcohol legalization among an American Indian Tribe. Plains Anthropologist 20(68):129-134. 1976 Alcohol Legalization and Native Americans: A Sociological Inquiry . Ph.D. Dissertation. University of Montana. 1977a Alcohol beverage control: A survey of tribal alcohol statutes. American Indian Law Review 5:217-228. 1977b Explanations of Native American drinking. Plains Anthropologist 22(77):223-232. 1982 Substance abuse and American Indians: Prevalence and susceptibility. International Journal on the Addictions 17:1185-1209. 1986 Alcohol and drug misuse prevention programs for American Indians: Needs and opportunities. Journal of Studies on Alcohol 47(3):187-195.

OCR for page 235
--> 1988 Mental health and alcohol abuse indicators in the Albuquerque area of the Indian Health Service: An exploratory chart review. American Indian and Alaska Native Mental Health Research 2(1):31-44. 1989a Alcohol abuse and alcoholism among American Indians: An overview. Pp. 95-119 in T.D. Watts and R. Wright, eds., Alcoholism in Minority Populations. Springfield, IL: Charles C Thomas. 1989b Motor vehicle crashes and alcohol among American Indians and Alaska Natives. Pp. 207-223 in The Surgeon General's Workshop on Drunk Driving: Background Papers . Washington, D.C.: U.S. Department of Health and Human Services. 1991 Fetal alcohol effects among North American Indians: Evidence and implications for society. Alcohol, Health and Research World 15(3): 239-248. 1992 Alcohol policy considerations for Indian reservations and bordertown communities. American Indian and Alaska Native Mental Health Research 4(3):5-59. 1994a The epidemiology of alcohol abuse among American Indians: Mythical and real properties. American Indian Culture and Research Journal 18(2):121-143. 1994b Alcohol abuse. Pp. 23-27 in Mary B. Davis, ed., Native America in the Twentieth Century: An Encyclopedia. New York: Garland Press. 1995 The prevention of alcohol and other substance abuse among American Indians: A review and analysis of the literature. In P. Langton, ed., The Challenge for Participating Research in the Prevention of Alcohol-related Problems in Ethnic Communities. Washington, D.C.: National Institute on Alcohol Abuse and Alcoholism and Center for Substance Abuse Prevention. May, P.A., K.J. Hymbaugh, J.M. Ase, and J.M. Samet 1983 Epidemiology of Fetal Alcohol Syndrome among American Indians of the southwest. Social Biology 30:374-387. May, P.A., J.H. Miller, and N. Wallerstein 1993 Motivation and community prevention of substance abuse. Experimental and Clinical Psychopharmacology 1(1-4):68-79. May, P.A., and J.R. Moran 1995 Prevention of alcohol misuse: A review of health promotion efforts among American Indians. American Journal of Health Promotion 9(4):288-299. May, P.A., and M.B. Smith 1988 Some Navajo Indian opinions about alcohol abuse and prohibition: A survey and recommendations for policy. Journal of Studies on Alcohol 49:324-334. Miller, W.H., and S. Rollnick 1991 Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guilford Press. Mohatt, G. 1972 The sacred water: The quest for personal power through drinking among the Teton Sioux. Pp. 261-275 in McClelland et al., eds., The Drinking Man. New York: The Free Press. National Institute on Alcohol Abuse and Alcoholism (NIAAA) 1993 Alcohol and Health: Eight Special Report to the U.S. Congress . Washington, D.C.: U.S. Department of Health and Human Services. New Mexico Department of Health 1994 Selected Health Statistics, Annual Report, 1992. Sante Fe: Bureau of Vital Records and Health Statistics. Oetting, E.R., and F. Beauvais 1989 Epidemiology and correlates of alcohol use among Indian adolescents living on reservations. Pp. 239-267 in Alcohol Use Among U.S. Ethnic Minorities. NIAAA Research Monograph No. 18, Rockville, MD: U.S. Public Health Service.

OCR for page 235
--> Oetting, E.R., F. Beauvais, and R.W. Edwards 1988 Alcohol and Indian youth: Social and psychological correlates and prevention. Journal on Drug Issues 18:87-101. Oetting, E.R., R.C. Swain, R.W. Edwards, and F. Beauvais 1989 Indian and Anglo adolescent alcohol use and emotional distress: Path models. American Journal of Drug and Alcohol Abuse 15(2):153-172. Pittman, D.J., and H.R. White 1991 Society, Culture and Drinking Patterns Reexamined. New Brunswick, NJ: Rutgers Center on Alcohol Studies. Reed, T.E., H. Kalant, R.J. Griffins, B.M. Kapur, and J.G. Rankin 1976 Alcohol and acetaldehyde metabolism in Caucasians, Chinese and Americans. Canadian Medical Association Journal 115:851-855. Rex, D.K., W.F. Bosion, J.E. Smialek, and T-K Li 1985 Alcohol and aldehyde dehydrogenase isoenzymes in North American Indians. Alcoholism: Clinical and Experimental Research 9(2):147-152. Robinson, G.C., J.L Coury, and R.F.Coury 1987 Clinical people and prevalence of FAS in an isolated community of British Columbia. Canadian Medical Association Journal 137:203-207. Schaefer, J.M. 1981 Firewater myths revisited. Journal of Studies on Alcohol 9:99-117. Segal, B., and L.K. Duffy 1992 Ethanol elimination among different racial groups. Alcohol 9:213-217. Sellers, C.S., and L.T. Winfree 1990 Differential associations and definitions: A panel study of youthful drinking behavior. International Journal on the Addictions 25(7):755-771. Shore, J.H. 1974 Psychiatric epidemiology among American Indians. Psychiatric Annals 4(11):56-66. Shore, J.H., and L. Kofoed 1984 Community intervention in the treatment of alcoholism. Alcoholism: Clinical and Experimental Research 8(2):151-159. Shore, J.H., and B. Von Fumetti 1972 Three alcohol programs for American Indians. American Journal of Psychiatry 128(11):1450-1454. Stewart, O.C. 1964 Questions regarding American Indian criminality. Human Organization 23(1):64-76. Stratton, J. 1973 Cops and drunks: Police attitude and actions in dealing with Indian drunks. International Journal of the Addictions 8(4):613-621. Swaim, R.C., E.R. Oetting, P.J. Thurman, F. Beauvais, and R.W. Edwards 1993 American Indian Adolescent Drug Use and Socialization Characteristics: A Cross Cultural Comparison. Journal of Cross Cultural Psychology 24(1):53-71. Swanson, D.W., A.P. Beatrude, and E.M. Brown 1971 Alcohol abuse in a population of Indian children. Diseases of the Nervous System 12:835-842. Topper, M. 1980 Drinking as an expression of status: Navajo male adolescents. Pp. 103-147 in J.O. Waddel and M.W. Everett, eds., Drinking Behavior among South-western Indians. Tucson, AZ: The University of Arizona Press. Van Norman, M.C. 1992 Alcohol beverage control policy: Implementation on a Northern Plains Indian reservation. American Indian and Alaska Native Mental Health Research 4(3):120-125.

OCR for page 235
--> Van Winkle, N.W., and P.A. May 1993 An update on American Indian suicide in New Mexico, 1980-1987. Human Organization 52(3):304-315. Welty, T.K. 1988 Planned Approach to Community Health. Rapid City, SD: U.S. Indian Health Service. Welty, T.K., E.T. Lee, J. Yeh, L.D. Cowan, O. Go, R.R. Fabsitz, N.A. Le, A.J. Oopik, D.C. Robbins, and B.V. Howard 1995 Cardiovascular disease risk factors among American Indians: The Strong Heart Study. American Journal of Epidemiology 142(3):269-287. Whittaker, J.O. 1962 Alcohol and the Standing Rock Sioux Tribe. Quarterly Journal of Studies on Alcohol 23:468-479. 1982 Alcohol and the Standing Rock Sioux Tribe: A twenty-year follow-up study. Journal of Studies on Alcohol 43:191-200. Wilson, L.G., and J.H. Shore 1975 Evaluation of a regional Indian alcohol program. American Journal of Psychiatry 132:255-258. Winfree, L.T., and C.T. Griffiths 1985 Trends in drug orientations and behavior: Changes in a rural community, 1975-1982 . International Journal on the Addictions 20(10):1495-1508. Winfree, L.T., C.T. Griffiths, and C.S. Sellers 1989 Social learning theory, drug use, and American Indian youths: A cross-cultural test. Justice Quarterly 6(3):395-417. Young, T.K. 1994 The Health of Native Americans: Toward a Biocultural Epidemiology . New York: Oxford University Press.